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2012

MAINTENANCE STRATEGIES

© Copyright, The Joint Commission


George Mills, Director

Engineering Department

The Joint Commission

EC.02.05.01 EP 2

The hospital maintains a written inventory of all operating components of utility systems or maintains a written inventory of selected operating components of utility systems based on risks for infection, occupant needs, and systems critical to patient care

Department of Engineering 2012 - 2


and systems critical to patient care (including all life-support systems).

The hospital evaluates new types of utility components before initial use to determine whether they should be included in the inventory.

(See also EC.02.05.05, EPs 1, 3-5)

MAINTAINING UTILITIES EQUIPMENT

� Inventory is populated based on one of two strategies:

�All equipment inclusion

�Based on physical risks for

� Infection

� Occupant needs



� Occupant needs

� Systems critical to patient care

� All life support equipment is included

� All new types of equipment is evaluated for inclusion

JOINT COMMISSION UTILITIES EQUIPMENT

Utility System as defined in the Accreditation Manuals Glossary and EC.02.05.03 include:

� Electrical distribution

� Emergency Power Supply System (EPSS)

� Vertical & Horizontal Transport

Heating, Ventilation & Air Conditioning



�Heating, Ventilation & Air Conditioning

� Plumbing

� Boiler and Steam

� Piped Gases

� Vacuum Systems

�Communication Systems & Data Exchange

JOINT COMMISSION UTILITIES EQUIPMENT

� Specific Utility Systems include

� Features of Fire Safety (EC.02.03.01)

� Alarm and Notification (LS.02.01.34)

� Suppression Systems (LS.02.01.35)

� Design criteria (EC.02.05.01)

� Power Distribution System (EC.02.05.03)



� Power Distribution System (EC.02.05.03)

� Emergency Power Supply Systems (EC.02.05.07)

� Medical Gases (EC.02.05.09)

� Specific populations of equipment

� Life support systems (EC.02.05.05)

� Infection Control utility systems (EC.02.05.05)

EC.02.05.01 EP 3

The hospital identifies, in writing, inspection and maintenance activities for all operating components of utility systems on the inventory.

(See also EC.02.05.05, EPs 3 - 5; EC.02.05.09, EP 1)

Note: Hospitals may use different approaches to



Note: Hospitals may use different approaches to maintenance. For example, activities such as predictive maintenance, reliability- centered maintenance, interval-based maintenance, corrective maintenance, or metered maintenance may be selected to ensure dependable

performance.

MAINTAINING EQUIPMENT: STRATEGIES

� Written strategies identify the activities for

� Maintaining

� Inspection

� Testing

� Strategies may include

Predictive maintenance



� Predictive maintenance

� Reliability-centered maintenance

� Interval based maintenance

� Corrective maintenance

� Metered maintenance

� Other recognized strategy

� Manufacture’s recommendations


� Predictive Maintenance� The scheduled activities designed to extend equipment reliability based on performing activities prior to equipment failure based on risk levels and organization experience

� Interval Based Maintenance� The scheduled activities are based on a preset schedule that is established regardless of need



schedule that is established regardless of need� Determine Interval Time:

� Manufacturer’s guidelines� Accepted industry practices� Regulatory code requirements� Organization’s past experiences

� Most preventive maintenance software programs are “Interval-Based”


�Reliability-Centered Maintenance

�Based on historical analysis of the reliability of equipment

�Anticipated maintenance activities to extend the reliability based on



extend the reliability based on intersecting historical failure

�Metered Maintenance

�Based on established amount of time the equipment has operated rather than a calendar schedule


�Corrective Maintenance

�Equipment is not serviced based on preventive models, but allowed to run until repairs are needed

�Also includes response to any



Also includes response to any corrective measures related to the physical environment

�Other, such as manufacturer’s recommendations

� Always during warranty period

� Evaluate against other strategies

EC.02.05.01 EP 4

�The hospital identifies, in writing, the intervals for inspecting, testing, and maintaining all operating components of the utility systems on the inventory, based on criteria such as



based on criteria such as

�Manufacturer‘s recommendations

�Risk levels

�hospital experience

(See also EC.02.05.05, EPs 3-5)

MAINTENANCE FREQUENCIES

�Manufacturer’s Recommendations

�New equipment that has no operating history should follow manufacturer’s recommendations until enough history and level of risk has been established



and level of risk has been established

�Industry experience has established that often manufacturer’s recommendations are based on worse-case situations and may exceed the normal operating condition level maintenance activity


�Risk levels

� Evaluating the potential risk of equipment failure is a significant part of evaluating maintaining, inspecting and testing requirements

Based on physical risks impact for



�Based on physical risks impact for

� Infection

� Occupant needs

� Systems critical to patient care


�Hospital experience

�Evaluating the benefits of maintaining, inspecting and testing activities based on history may contribute to increasing or extending those activity periods



or extending those activity periods

EC.02.05.05: THE HOSPITAL INSPECTS, TESTS,

AND MAINTAINS UTILITY SYSTEMS

EP 2. The hospital inspects, tests, and maintains the following: Life support utility system components on the inventory. These activities are documented. (See also EC.02.05.01, EPs 2-4)

EP 3. The hospital inspects, tests, and maintains non-life support equipment identified on the



non-life support equipment identified on the medical equipment inventory. These activities are documented. (See also EC.02.04.01, EPs 2-4 and PC.02.01.11, EP 2)

EP 4. The hospital inspects, tests, and maintains the following: Infection control utility system components on the inventory. These activities are documented. (See also EC.02.05.01, EPs 2-4)

SURVEY PROCESS

�Document Review

� Evaluate the Management Plan

� Determine the Maintenance Strategies applied to the inspection, testing and maintenance of the equipment

Evaluate the work completion rates (% complete)



� Evaluate the work completion rates (% complete)

� To compute the percent complete divide the number of devices completed by the number of scheduled work orders

Example:

795 devices completed out of 825 scheduled = 96.4%

795 ÷ 825 = 96.36

SURVEY PROCESS

Evaluate the program documentation

� Logs are completed and reflect both Life Support Systems, Infection Control equipment, and Non-life support equipment on the inventory

� Accuracy of Inventory

� All Life Support equipment must be represented



� All Life Support equipment must be represented on the inventory

� Preventive maintenance frequencies must be clearly defined in writing

� Confirm work done as per scheduled activities

� Ensure appropriate work is scheduled based on maintenance strategies

� Evaluate equipment failure and scheduled actions

SURVEY PROCESS: STAFF INTERVIEWS

�Department Leader

� Establish how the inventory was created

� Establish the Maintenance Strategies used

� Evaluate the Monitoring processes

� Evaluate the effectiveness of the program



� Equipment Maintainers

� Evaluate their understanding of the maintenance process/strategies

� Evaluate competencies based on repeat work orders

� Evaluate work scheduled against completed

SURVEY PROCESS: STAFF INTERVIEW

�Users of the Equipment

� Evaluate equipment reliability

� Evaluate response time when equipment fails

� Evaluate emergency response process

� Evaluate “Culture of Safety”



� Appropriate training of staff related to equipment use

� Customer satisfaction with department

�Contract Services

� Evaluate reliability of equipment serviced

� Evaluate integration of the process

SURVEY PROCESS

� Evaluate the effectiveness of the program to maintain the equipment

� Repeat work orders

� Equipment turn-around time

� Completion rates



� Evaluate confidence of the users while using equipment

CMS CONDITIONS OF PARTICIPATION

�42 CFR 482.41

� Hospital must maintain adequate facilities for its services

� 42 CFR 482.41(c)(2)

� Facilities, supplies and equipment must be



� Facilities, supplies and equipment must be maintained to ensure an acceptable level of safety and quality.

� The CMS Interpretive Guideline states “the hospital must monitor, test, calibrate and maintain equipment periodically in accordance with the manufacturer’s recommendation and Fed and State law.”

CMS RESPONSE

I am happy to inform you that the Joint Commission’s approach of utilizing a preventive maintenance schedule has been approved.



schedule has been approved. Thank you for your cooperation and collaboration.

CMS Deputy DirectorJuly 26, 2010

S&C: 12-07-HOSPITAL

�Published 12/2011

�Allows non-life support to adjust maintenance frequencies

�Restricts non-life support from adjusting maintenance activities



adjusting maintenance activities

�Restricts life support from frequencies and maintenance activity adjustments

�Restricts equipment maintenance methods

DISCUSSION WITH CMS

�The Joint Commission had an opportunity to discuss the S&C: 12-07 4/9/2012

�Restriction related to test equipment lifted



�Collaborative discussion with the conclusion research would be of benefit

�Research should be specific to reliability of the Joint Commission process in EC.02.05.01

DISCUSSION, CONTINUED

�Research Issues:

�How many organizations use the Joint Commission process?

� What guidance is used to modify frequency and maintenance activities?



frequency and maintenance activities?

�Have there been any adverse outcomes based on solely on this process

� If so, what?

�Self diagnostic equipment:

� How many devices with this feature?

SURVEY MONKEY

�ASHE is hosting for Facilities:

� ASHE.ORG

� Select Facility Equipment Survey



�Clinical Engineering is hosted by AAMI at:

�https://www.surveymonkey.com/s/JCQuestionnaire

QUESTIONS?


DEPARTMENT OF ENGINEERING

630 792 5900

George Mills, MBA, FASHE, CEM, CHFM, CHSP

Director

Michael Chisholm, CPE, CHFM

Engineer



Anne Guglielmo, CFPS, LEED, A.P., CHSP

Engineer

Bruce Boggan, MBA/HCM, CHFM, RHSO

Engineer

THE JOINT COMMISSION DISCLAIMER

� These slides are current as of 5/15/2012. The Joint Commission reserves the right to change the content of the information, as appropriate.

� These slides are only meant to be cue points, which were expounded upon verbally by the original presenter and are not meant to be comprehensive statements of



and are not meant to be comprehensive statements of standards interpretation or represent all the content of the presentation. Thus, care should be exercised in interpreting Joint Commission requirements based solely on the content of these slides.

� These slides are copyrighted and may not be further used, shared or distributed without permission of the original presenter or The Joint Commission.

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